Employment Application

Employment Application Form:
Personal Information:
Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Birth Date*

MonthDayYear
Are you a U.S. Citizen?*

YesNo
Have you ever been convicted of a felony or misdemeanor?*

YesNo
Do you have a Driver's License*

YesNo
Do you have Professional Liability Insurance?*

YesNo
Are you currently licensed? If so, please list what license you currently hold and which state(s) it is held in. *
How were you referred to us?*

IndeedFacebookLinkedInEmployeeWalk-InOther
Employment Desired:
Position applying for*
Date You Can Start*

MonthDayYear
Employment Desired*

Full TimePart Time
Salary Desired
Amount in $
Expected Hourly Rate*
Amount in $
Have you worked here before?*

YesNo
Have you applied here before?*

YesNo

What is your current availability? (State all the hours you are available to work in the chart below.)*

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
From
To

Education:
High School*
Name of High School Attended
Number of Years Attended
Graduated?*

YesNoOther
College*
Name of College/University Attended
Number of Years Attended
Graduated?*

YesNoOther
Area of Study/Degree*
Graduate School*
Name of Graduate School Attended
Number of Years Attended
Graduated?*

YesNoOther
Area of Study/Degree*
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Graduated?

YesNoOther
Area of Study/Degree
Skills/Qualifications:
Describe your skills. What makes you a good fit for this position and what clinical expertise do you bring to this position? *
List any relevant skills
What is your ideal caseload? In terms of number of clients, demographics, presenting concerns, etc.*
Tell us about your personality. How would colleagues describe you?*
Please describe your therapeutic orientation.*
Please describe your approach towards providing culturally responsive, LGBTQ+ affirming, gender-affirming care.*
What are you passionate about?*
Please share one (or multiple) fun fact(s) about you.*
Training or Certifications
List any relevant certifications or qualifications
Current Employment:
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Salary
Reason for Leaving?
Start Date*

MonthDayYear
May We Contact?*

YesNo
Type of work performed*
Supervisor name and position*
Previous Employment:
Previous Employer*
Name of Previous Employer
Position*
Salary
Reason for Leaving?*
Start Date*

MonthDayYear
End Date*

MonthDayYear
May We Contact?*

YesNo
Type of work performed*
Supervisor name and position*
Previous Employer
Name of Previous Employer
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
May We Contact?

YesNo
Type of work performed
Supervisor name and position
References:

Please list three (3) references that are familiar with your work.
Reference 1*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Reference 2*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Reference 3*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Cover Letter & Resume (Optional):
Cover Letter*

Upload a File

Cancelof
Resume*

Upload a File

Cancelof
Send Application:
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employement may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.
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Employment Application Form:

Personal Information:

Employment Desired:

Education:

Skills/Qualifications:

Current Employment:

Previous Employment:

References:

Cover Letter & Resume (Optional):

Send Application: